EMBLOGS.ORG
LEARN. REFLECT. SHARE
Sedation in under 19s: using sedation for diagnostic and therapeutic procedures
Clinical guideline [CG112]Published: 15 December 2010
This guideline covers the assessment, preparation, training and monitoring needed when using sedation in people aged under 19.
The aims of sedation during diagnostic or therapeutic procedures include reducing fear and anxiety, augmenting pain control and minimising movement. The importance of each of these aims will vary depending on the nature of the procedure and the characteristics of the patient.
This guideline covers infants, children and young people under 19 years.
Infants: children from birth to 1 year.
Neonates: infants aged up to 1 month.
Levels of sedation
The definitions of minimal, moderate, conscious and deep sedation used in this guideline are based on those of the American Society of Anesthesiologists (ASA).
Minimal sedation: A drug‑induced state during which patients are awake and calm, and respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.
Moderate sedation: Drug‑induced depression of consciousness during which patients are sleepy but respond purposefully to verbal commands (known as conscious sedation in dentistry, see below) or light tactile stimulation (reflex withdrawal from a painful stimulus is not a purposeful response). No interventions are required to maintain a patent airway. Spontaneous ventilation is adequate. Cardiovascular function is usually maintained.
Conscious sedation: Drug‑induced depression of consciousness, similar to moderate sedation, except that verbal contact is always maintained with the patient. This term is used commonly in dentistry.
Deep sedation: Drug‑induced depression of consciousness during which patients are asleep and cannot be easily roused but do respond purposefully to repeated or painful stimulation. The ability to maintain ventilatory function independently may be impaired. Patients may require assistance to maintain a patent airway. Spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.
Specialist sedation techniques
Sedation techniques that have a reduced margin of safety and increased risk of unintended deep sedation or anaesthesia, accompanied by airway obstruction and/or inadequate spontaneous ventilation. Healthcare professionals using specialist sedation techniques need to be trained to administer sedation drugs safely, to monitor the effects of the drug and to use equipment to maintain a patent airway and adequate respiration.
At the time of publication of this guideline (December 2010), no drugs have a UK marketing authorisation specifically for sedation in all ages of infants, children and young people under 19.
Prescribers should follow relevant professional guidance, taking full responsibility for the decision, and consulting with experts as needed.
They should use a drug’s summary of product characteristics and the British national formulary for children to inform decisions made with individual patients.
The patient (or those with authority to give consent on their behalf) should provide informed consent, which should be documented. See the General Medical Council’s Good practice in prescribing and managing medicines and devices for further information.
Ensure that trained healthcare professionals carry out pre‑sedation assessments and document the results in the healthcare record.
Establish suitability for sedation by assessing all of the following:
current medical condition and any surgical problems
weight (growth assessment)
past medical problems (including any associated with previous sedation or anaesthesia)
current and previous medication (including any allergies)
physical status (including the airway)
psychological and developmental status.
Seek advice from a specialist before delivering sedation:
if there is concern about a potential airway or breathing problem
if the child or young person is assessed as American Society of Anesthesiologists (ASA) grade 3[1] or greater
for infants, including neonates.
Ensure that both the following will be available during sedation:
a healthcare professional and assistant trained (see section 1.4) in delivering and monitoring sedation in children and young people
immediate access to resuscitation and monitoring equipment (see section 1.5).
Choose the most suitable sedation technique based on all the following factors:
what the procedure involves
target level of sedation
contraindications
side effects
patient (or parent or carer) preference.
Healthcare professionals delivering sedation should have knowledge and understanding of and competency in:
sedation drug pharmacology and applied physiology
assessment of children and young people
monitoring
recovery care
complications and their immediate management, including paediatric
life support.
Healthcare professionals delivering sedation should have practical experience of:
effectively delivering the chosen sedation technique and managing complications
observing clinical signs (for example, airway patency, breathing rate and depth, pulse, pallor and cyanosis, and depth of sedation)
using monitoring equipment.
Ensure that members of the sedation team have the following life support skills:
| Minimal sedation a | Moderate sedation | Deep sedation |
All members | Basic | Basic | Basic |
At least one member |
| Intermediate | Advanced |
a including sedation with nitrous oxide alone (in oxygen) and conscious sedation in dentistry. | |||
Healthcare professionals delivering sedation should have documented up‑to‑date evidence of competency including:
satisfactory completion of a theoretical training course covering the principles of sedation practice
a comprehensive record of practical experience of sedation techniques, including details of:
sedation in children and young people performed under supervision
successful completion of work‑based assessments.
[1] The ASA physical status classification system (grades 1–6) is a system to classify and grade a patient’s physical status before anaesthesia.
[2] For deep sedation, the healthcare professional administering sedation should be involved only in continuously monitoring, interpreting and responding to all of the above.
[3] End tidal CO2 and blood pressure should be monitored, if possible, provided that monitoring does not cause the patient to awaken and so prevent completion of the procedure.
Before starting sedation, confirm and record the time of last food and fluid intake in the healthcare record.
Fasting is not needed for:
minimal sedation
sedation with nitrous oxide (in oxygen)
moderate sedation during which the child or young person will maintain verbal contact with the healthcare professional.
Refer to professional guidance for fasting for deep sedation and moderate sedation during which the child or young person might not maintain verbal contact with the healthcare professional.
For an emergency procedure in a child or young person who has not fasted, base the decision to proceed with sedation on the urgency of the procedure and the target depth of sedation.
Healthcare professionals delivering sedation should have knowledge and understanding of and competency in:
sedation drug pharmacology and applied physiology
assessment of children and young people
monitoring
recovery care
complications and their immediate management, including paediatric life support.
Healthcare professionals delivering sedation should have practical experience of:
effectively delivering the chosen sedation technique and managing complications
observing clinical signs (for example, airway patency, breathing rate and depth, pulse, pallor and cyanosis, and depth of sedation)
using monitoring equipment.
Ensure that members of the sedation team have the following life support skills:
| Minimal sedation a | Moderate sedation | Deep sedation |
All members | Basic | Basic | Basic |
At least one member |
| Intermediate | Advanced |
a Including sedation with nitrous oxide alone (in oxygen) and conscious sedation in dentistry. | |||
Ensure that a healthcare professional trained in delivering anaesthetic agents[6] is available to administer:
sevoflurane
propofol
opioids combined with ketamine.
Healthcare professionals delivering sedation should have documented up‑to‑date evidence of competency including:
satisfactory completion of a theoretical training course covering the principles of sedation practice
a comprehensive record of practical experience of sedation techniques, including details of:
sedation in children and young people performed under supervision
successful completion of work‑based assessments.
Each healthcare professional and their team delivering sedation should ensure they update their knowledge and skills through programmes designed for continuing professional development.
Consider referring to an anaesthesia specialist a child or young person who is not able to tolerate the procedure under sedation.
Ensure that all of the following criteria are met before the child or young person is discharged:
vital signs (usually body temperature, heart rate, blood pressure and respiratory rate) have returned to normal levels
the child or young person is awake (or returned to baseline level of consciousness) and there is no risk of further reduced level of consciousness
nausea, vomiting and pain have been adequately managed.
For children and young people undergoing a painful procedure (for example suture laceration or orthopaedic manipulation), when the target level of sedation is minimal or moderate, consider:
nitrous oxide (in oxygen) and/or
midazolam (oral or intranasal)[
For all children and young people undergoing a painful procedure, consider using a local anaesthetic, as well as a sedative.
For children and young people undergoing a painful procedure (for example, suture laceration or orthopaedic manipulation) in whom nitrous oxide (in oxygen) and/or midazolam (oral or intranasal) are unsuitable consider[6]:
ketamine (intravenous or intramuscular), or
intravenous midazolam with or without fentanyl (to achieve moderate sedation).
For children and young people undergoing a painful procedure (for example suture laceration or orthopaedic manipulation) in whom ketamine (intravenous or intramuscular) or intravenous midazolam with or without fentanyl (to achieve moderate sedation) are unsuitable, consider a specialist sedation technique such as propofol with or without fentany